An Interesting Case of Deceased-donor Renal Transplant with High Donor-specific Antibody by Desensitization

In general, presence of positive donor-specific anti-human leukocyte antigen antibody (DSA) by single-antigen bead (SAB) assay and positive antihuman globulin-enhanced complement-dependent-cytotoxicity crossmatch (AHG-CDC-LCM) and flow cytometry crossmatch (FCM) is considered a contraindication to kidney transplant (KTx). This is a case report describing successful KTx in a patient enrolled in cadaver transplant list who was initially rejected in view of positive AHG-CDC-LCM and FCM with DSA >5000 mean fluorescence intensity (MFI). This is a case report of a 34-year-old female highly sensitized patient with no potential live donor, enrolled in a deceased-donor program and rejected multiple times due to positive flow crossmatch. The patient was subjected to five sessions of plasma exchange (PLEX) and three doses of bortezomib as per our institute’s desensitization protocol. One more PLEX (6 th ) was done once her name came before cadaver transplant. Creatinine on day 7 was 0.81 mg/dl, and DSA was <5000 MFI. However, again, after 2 weeks, when creatinine rose to 1.5 mg/dl, SAB-DSA was repeated which was >10,000 MFI. This time Immunocore single-use filter was used, and PLEX was done without volume replacement, followed by three more regular PLEX. Again, creatinine declined to 0.86 mg/dl with DSA <10000 MFI. Even after 12 months of renal transplant, creatinine is 0.8 mg/dl. Our report suggests that renal transplant can be considered with DSA >5000 MFI with negative (AHG-CDC-LCM) and (FCM) with desensitization even in deceased-donor transplant with intensified immunosuppression and follow-up with SAB assay even without protocol biopsy.